Sean Cunningham

PFD Report Historic (No Identified Response) Ref: 2014-0087
Date of Report 26 February 2014
Coroner S P Fisher
Response Deadline est. 23 April 2014
No published response · Over 2 years old
Sent To
Response Status
Responses 0 of 1
56-Day Deadline 23 Apr 2014
Over 2 years old — no identified published response
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner's Concerns
Martin Baker (the manufacturers of the ejection seat) continue to manufacture and the MOD continue to operate aircraft incorporating ejection seats in respect of which there continues to be a significant risk of the strapping-in process impacting negatively on the safe operation of ejection seat, principally in consequence of strap misrouting: This risk continues' despite pilot instruction, training and specific warning to seek to ensure that it does not occur; My concern is that no design solution, to a well-established problem in this regard, has yet been found. It is not clear to me at the end of this inquiry as to whether Martin Baker Aircraft have a sufficiently comprehensive, robust and auditable system in place that will ensure that in the event of a need for a warning or a safety critical alteration to maintenance procedures being issued in the future, it will be sent to and received by all end users of the applicable seat or seats within an appropriate timescale. My concern relates the companies process for the urgent dissemination of safety critical information in this respect:
Action Should Be Taken
the safety
Report Sections
Investigation and Inquest
On 22nd November 2011 commenced an investigation into the death of Sean James Cunningham, age 35. The investigation concluded at the end of the inquest on 29"h January 2014, The conclusion of the inquest was a narrative conclusion
Circumstances of the Death
On the 11 November 2011, the deceased ejected from an aircraft: His parachute failed to deploy and he suffered fatal injuries as a result of a fall to the ground.
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Uniform policy for obtaining technical advice
Scottish Hospitals Inquiry
Major project lessons learned
Streamlining NHS construction quality procedures
Scottish Hospitals Inquiry
Major project lessons learned
Information on common construction errors
Scottish Hospitals Inquiry
Major project lessons learned
Independent validation of hospital construction
Scottish Hospitals Inquiry
Major project lessons learned
Clarify whether HCRS and OCS assessment processes differ
Post Office Horizon Inquiry
Major project lessons learned
MAIB publication of implementation measures
Cranston Inquiry
Major project lessons learned
Reconsider Phase 1 recommendations in light of Phase 2
Grenfell Tower Inquiry
Major project lessons learned
Reconsider LGA Guide paragraph 79.11 advice
Grenfell Tower Inquiry
Major project lessons learned
Add legal requirements warning to statutory guidance
Grenfell Tower Inquiry
Major project lessons learned
Include academics on statutory guidance advisory bodies
Grenfell Tower Inquiry
Major project lessons learned

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.